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Glenohumeral joint injection: A comparative study of ultrasound and

fluoroscopically guided techniques before MR arthrography

Article  in  European Radiology · October 2008

DOI: 10.1007/s00330-008-1200-x · Source: PubMed

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Eur Radiol (2009) 19: 722–730
DOI 10.1007/s00330-008-1200-x MUSCULO SKELETAL

Matthieu J. C. M. Rutten
James M. P. Collins
Glenohumeral joint injection: a comparative
Bas J. Maresch
Jacques H. J. M. Smeets
study of ultrasound and fluoroscopically guided
Caroline M. M. Janssen techniques before MR arthrography
Lambertus A. L. M. Kiemeney
Gerrit J. Jager

Received: 30 June 2008
Accepted: 19 September 2008
Published online: 29 October 2008
# The Author(s) 2008
M. J. C. M. Rutten (*) .
C. M. M. Janssen . G. J. Jager
Department of Radiology, Jeroen
Bosch Hospital,
Nieuwstraat 34,
5211 NL
‘s-Hertogenbosch, The Netherlands
e-mail: m.rutten@jbz.nl
Tel.: +31-73-6992000
Fax: +31-73-6992601
e-mail: c.janssen@jbz.nl
e-mail: g.jager@jbz.nl
J. M. P. Collins
Department of Radiology,
Medical Centre Leeuwarden,
H. Dunantweg 2,
8934 AD
Leeuwarden, The Netherlands
e-mail: j.collins@znb.nl
B. J. Maresch
Department of Radiology, Hospital
Gelderse Vallei,
Willy Brandtlaan 10,
6716 RP Ede, The Netherlands
e-mail: mareschb@zgv.nl
J. H. J. M. Smeets
Department of Radiology, Slingeland
Hospital,
Kruisbergseweg 25,
7009 BL Doetinchem, The Netherlands
e-mail: jsmeets@planet.nl
L. A. L. M. Kiemeney
Department of Epidemiology and
Biostatistics, Radboud University
Nijmegen Medical Centre,
Geert Grooteplein Noord 21,
P.O. Box 9101, 6500 HB
Nijmegen, The Netherlands
e-mail: b.kiemeney@ebh.umcn.nl
Abstract To assess the variability in
accuracy of contrast media introduc-
tion, leakage, required time and pa-
tient discomfort in four different
centres, each using a different image-
guided glenohumeral injection tech-
nique. Each centre included 25
consecutive patients. The ultrasound-
guided anterior (USa) and posterior
approach (USp), fluoroscopic-guided
anterior (FLa) and posterior (FLp)
approach were used. Number of in-
jection attempts, effect of contrast
leakage on diagnostic quality, and
total room, radiologist and procedure
times were measured. Pain was docu-
mented with a visual analogue scale
(VAS) pain score. Access to the joint
was achieved in all patients. A suc-
cessful first attempt significantly oc-
curred more often with US (94%) than
with fluoroscopic guidance (72%).
Leakage of contrast medium did not
cause interpretative difficulties. With
US guidance mean room, procedure
and radiologist times were signifi-
cantly shorter (p<0.001). The USa
approach was rated with the lowest
pre- and post-injection VAS scores.
The four image-guided injection
techniques are successful in injection
of contrast material into the glenohu-
meral joint. US-guided injections and
especially the anterior approach are
significantly less time consuming,
more successful on the first attempt,
cause less patient discomfort and
obviate the need for radiation and
iodine contrast.
Keywords Ultrasound .
Fluoroscopy . Shoulder . Image-
guided injection . MR arthrography

Introduction Deposition of contrast media into the glenohumeral

MR arthrography is frequently performed in the assessment
of shoulder problems [1]. Intra-articular injection of a
gadolinium chelate or a saline solution improves the
detection of rotator cuff tears and demonstration of the
labrum [1].
joint may be a challenge for some radiologists. According
to the numerous publications on this subject, it is still an
item of investigation [2–20]. There are various techniques
from blind [4,17,19] to image guided [2,3,10,12]. Gleno-
humeral injections are generally performed using an
anterior approach under fluoroscopic guidance, which

was first described in 1933 by Oberholzer [21] and
modified by Schneider [22]. Other methods for intra-
articular injection of the glenohumeral joint have been
described, e.g., fluoroscopically guided using a posterior
approach [9, 10], palpation directed [4, 19], ultrasound
(US) [2, 3, 14], CT [11] and MR guided [7, 20]. These
studies deal mostly with the techniques and/or their
feasibility. Nowadays there is growing interest in evaluat-
ing and improving radiologists’ interpretive performance
and efficiency in delivering patient care. However, little is
known about differences in accuracy of contrast injection,
the effect of contrast leakage on image interpretation [19],
the time taken and the discomfort experienced by the
patient [23, 24] among different radiologists using
different techniques.
The purpose of our study was to prospectively assess the
variation in accuracy, effect of leakage of contrast medium
on diagnostic quality, the time required and the discomfort
experienced by the patient for the introduction of contrast
material into the glenohumeral joint with four different
frequently applied image-guided (fluoroscopy and US)
injection techniques.
Materials and methods
Patients
A prospective study was performed in four centres each
including 25 consecutive patients with shoulder instability
who were referred for MR arthrography by orthopaedic
surgeons. Patient characteristics are illustrated in Table 1.
Patients who had previously undergone shoulder surgery
were excluded. Institutional review board approval and
verbal consent were obtained.
Four radiologists in four different centres were deliberately
chosen because each routinely used a different approach for
glenohumeral injection. In this way we were able to audit and
compare the daily practice of various glenohumeral humeral
injection techniques applied by experienced musculoskeletal
radiologists (>9 years of experience each). In each centre a
different intra-articular approach was applied by an experi-
Table 1 Four patient groups
Patients Gender
No. M F
FLa 25 17 7 39/44
FLp 25 14 11
USa 25 16 9 35/34
USp 25 19 6 36/37
Number of patients per group, gender, age and sidedness of the punctured shoulders are displayed
USa: US-guided anterior injection, USp: US-guided posterior injection, FLa: fluoroscopic-guided anterior injection, FLp: fluoroscopic-
guided posterior injection
723
enced musculoskeletal radiologist, fluoroscopic-guided ante-
rior (FLa), fluoroscopic-guided posterior (FLp), US-guided
anterior (USa) and US-guided posterior (USp).
All patients underwent intra-articular injection of
gadoterate meglumine (gadoteric acid) 0.0025 mmol/ml
(Artirem®; Guerbet S.A., Villepinte, France), which is a
dilution (1:200) of Dotarem® (Gd-DOTA) provided in pre-
filled syringes of 20 ml, until intra-articular pressure rose or
up to a maximum of 20 ml.
Injection techniques
All radiologists used the technique and materials with
which they were familiar. The FLp and Fla injections were
performed with a 1.2 mm×88.9-mm spinal needle (18-
gauge, 3.5 inch) and a 0.9×90-mm spinal needle (20
gauge), respectively, and the US-guided injections with a
0.8×50-mm bevelled needle (21-gauge) without a stylet.
The Fla injections are performed with the patient supine in
a straight anteroposterior position with the shoulder slightly
externally rotated. The needle is directed vertically under
fluoroscopic control at the junction of the middle and lower
thirds of the medial part of the humeral head (Figs. 1 and 3).
See also Figs. 2 and 3.
The Flp injections are performed in prone position with
the symptomatic shoulder slightly raised until the gleno-
humeral joint is seen tangentially [9, 10]. The injection site
is infiltrated with local anaesthetic [prilocaïnehydrochlor-
ide 10 mg/ml (Citanest® 1%), Astra Pharmaceutica,
Zoetermeer, The Netherlands] using a 0.8×50-mm bev-
elled needle (21 gauge). With the shoulder in a neutral
position or slightly internally rotated, the needle is aimed at
the inferomedial quadrant of the humeral head and
advanced vertically under fluoroscopic guidance to the
cartilage of the humeral head (Figs. 2 and 4) [9, 10].
The USa approach was performed according to Valls [3].
Patients are supine with the shoulder slightly externally
rotated. A HDI 5000 SonoCT (ATL/Philips, Best, The
Netherlands) with a 5–8-MHz curved array transducer was
used to visualise the needle (Fig. 5A). After skin and
transducer preparation with alcohol 70%, the patient’s
Age Sidedness
Mean/median (range) L R
(14–69) 9 16
44/44 (28–62) 14 11
(18–59) 9 16
(16–69) 10 15
724
Fig. 1 Schematic drawing of the anterior view of the right shoulder
showing the puncture sites of the fluoroscopic- (X) and US-guided
(●) anterior injection techniques
shoulder was draped in sterile fashion. The needle is
inserted at the level of the coracoid, from lateral to medial,
aimed at the medial border of the humeral head (Figs. 1 and 5)
[3]. The contrast medium can be seen flowing in the direction
of the subscapular recess and joint space.
The USp approach, described by Cicak [2] and modified
by Zwar [14], was performed using a APLIO US machine
(Toshiba Medical Systems Corporation, Tokyo, Japan)
with a 7.5–14-MHz linear array transducer (Toshiba PLF-
Fig. 2 Schematic drawing of the posterior view of the right
shoulder showing the puncture sites of the fluoroscopic- (X) and
US-guided (●) posterior injection techniques
Fig. 3 Fluoroscopic-guided anterior approach. X-ray of the anterior
view of a right-hand shoulder showing the needle entry site. The
needle is inserted vertically at the inferomedial quadrant of the
humeral head. The intra-articular position of the needle tip is
confirmed by injecting a little iodinated contrast media, which
demarcates the hyaline cartilage (black arrows) of the humeral head
805ST). The patient is either lying obliquely prone on the
contralateral shoulder or sitting upright with the back to the
radiologist and the ipsilateral hand on the contralateral
shoulder. After skin and transducer preparation with
alcohol 70%, the patient’s shoulder was draped in sterile
fashion. The needle is inserted, from lateral to medial,
parallel to the long axis of the transducer and advanced
under US control in the joint between the humeral head and
the posterior glenoid labrum (Figs. 2 and 6) [14].
Fig. 4 Fluoroscopic-guided posterior approach. X-ray of the
posterior view of a right-hand shoulder showing the needle entry
site. The needle is inserted vertically at the inferomedial quadrant of
the humeral head. The intra-articular position of the needle tip is
confirmed by injecting a little iodinated contrast media, which
demarcates the hyaline cartilage (black arrow) of the humeral head
 725

Fig. 5 US-guided anterior ap-

proach. a Sonogram of a right-
hand shoulder showing the needle
track (arrows) from lateral to
medial with the USa approach.
The needle is inserted at the level
of the coracoid (C). The tip of the
needle is in intra-articular posi-
tion with the tip underneath the
subscapular tendon (SSC) and
bordering the humeral head (H).
b Corresponding cadaver section
showing the optimal needle track
(white line)

Evaluation of intra-articular administration of contrast

Time assessment material

To be able to monitor the time taken for the procedure in
four different centres, with different personel, a simple
method of scoring how things were done was standardised.
Room time (time between the patient entering and leaving
the room), radiologist time (time between entering and
leaving the room) and procedure time (time between starting
and ending the injection procedure) were recorded. Mean
times were assessed, and because of the maximum time of
Fla and Flp, we also assessed the median times (Table 3).
The number of attempts needed to enter the joint space was
recorded. An attempt to inject a joint was defined as the need
for repositioning of the needle after unsuccessful test injection.
The joint space was considered to be entered when the
needle contacted the humeral head cartilage, test injection
was performed without resistance and the intra-articular
position of contrast material was confirmed with fluoros-
copy by injection of 1–2 ml iodinated nonionic contrast
(Omnipaque 300; Amersham Cygne, Eindhoven, The

Fig. 6 US-guided posterior approach. a Sonogram of a right-hand
shoulder showing the needle track (arrows) from lateral to medial
with the USp approach. The needle is inserted at the midlevel of the
humeral head (H). The needle is in intra-articular position with the
tip underneath the infraspinatus tendon (ISP) and posterior labrum
(L) and bordering the hyaline cartilage (asterisks) of the humeral
head. G: glenoid. b Corresponding cadaver section showing the
optimal needle track (white line). c Sonogram following injection of
15 ml injected gadoterate meglumine (Artirem®) (asterisk). The
correct intra-articular position of the needle (arrows) can be
visualised real-time during injection, but is also confirmed by the
‘comma’-like configuration of the posterior labrum (arrowheads),
which is lifted by the intra-articularly injected fluid (asterisk). G:
glenoid, H: humearal head, ISP: infraspinatus tendon
726

Netherlands). Confirmation with real time US can be
performed without the use of iodinated contrast media by
visualising the intra-articular flow of fluid during injection or
by visualising the intra-articularly injected fluid underneath
the capsule and/or labrum posteriorly and underneath the
subscapular tendon anteriorly, or around the long head of the
biceps tendon.
The amount of injected contrast material was recorded.
MR imaging was performed within 15 min of the injection
with a 1.0-T or a 1.5-T MR system. In all centres a dedicated
receive-only shoulder coil was used. Images were used for
diagnostic purpose and to assess retrospectively the intra-
articular position and contrast leakage by an independent
blinded radiologist who did not perform the procedure.
Leakage was graded using a five-grade scale (Table 2).
were non-normally distributed, nonparametric Kruskal-
Wallis tests were used to test for statistical differences.
Statistical significance was accepted if the P value was
less than 0.05. The comparisons between the techniques
were not adjusted for the patients’ sex, age or right or
left shoulder. The distribution of all categorical variables
was presented in frequencies. Differences in these
distributions were tested for statistical significance
using chi-square tests.
All statistical analyses were performed using SPSS,
version 14.0.2 for Windows (Chicago, IL) by an
experienced statistician (L.K.).
Results

Visual analogue scale
Before and after injection, patients graded their anticipated
and experienced level of pain. A visual analogue scale
(VAS) was used, with a scale from 0 (“no pain”) to 100
(“unbearable pain”). Complications were recorded.
Statistical analysis
For descriptive purposes, mean and standard deviations
are reported for room time, radiologist time, total
procedure time and VAS scores. Because the variables
Patient groups
As illustrated in Table 1, the patient groups involved in this
study were quite similar in sex, age distribution and
sidedness of the affected shoulder. There was a slight
predominance in right shoulders, as one might expect, as
most people are right-handed. Patients’ gender and left or
right shoulder were not significantly related to room time,
radiologist time, total procedure time and difference
between the pre- and post-procedure VAS scores. The
age of the patients was only weakly (r2 <0.04) correlated
with the three time variables and not at all correlated with
the VAS score difference. Therefore, the analyses were not
adjusted for age, sex and laterality.

Table 2 Accuracy, number of attempts to gain access to the glenohumeral joint, injected volume and leakage of contrast media with four
different image-guided approaches
Overall FLa FLp USa USp FL(a + p) US(a + p)
Number of patients (N) 100 25 25 25 25 50 50

Intra-articular injection 100 (100%) 25 (100%) 25 (100%) 25 (100%) 25 (100%) 50 (100%) 50 (100%)
1st attempt 83 (83%) 19 (76%) 17 (68%) 24 (96%) 23 (92%) 36 (72%) 47 (94%)
2nd attempt 14 (14%) 5 (20%) 6 (24%) 1 (4%) 2 (8%) 11 (22%) 3 (6%)
3rd attempt 3 (3%) 1 (4%) 2 (8%) 0 (0%) 0 (%) 3 (6%) 0 (0%)
No leakage 49 (49%) 8 (32%) 13 (52%) 16 (64%) 12 (48%) 21 (42%) 28 (56%)
Minimal leakage noncompromising 24 (24%) 12 (48%) 3 (12%) 4 (16%) 5 (20%) 15 (30%) 9 (18%)
Massive leakage noncompromising 27 (27%) 5 (20%) 9 (36%) 5 (20%) 8 (32%) 14 (28%) 13 (26%)
Minimal leakage compromising 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Massive leakage compromising 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Minimal injected volume (ml) 5.0 10.0 9.0 5.0 10.0 9.0 5.0
Maximal injected volume (ml) 20.0 20.0 20.0 20.0 20.0 20.0 20.0
Mean injected volume (ml) 15.6 14.5 14.9 14.6 18.6 14.7 16.6
Local anaesthetics – No Yes No No – –
Needle size (gauge) – 20 18 21 21 – –
USa: US-guided anterior injection, USp: US-guided posterior injection, FLa: fluoroscopic-guided anterior injection, FLp: fluoroscopic-
guided posterior injection, FL (a + p): fluoroscopic-guided anterior and posterior approach, US (a + p): US-guided anterior and posterior
approach

Accuracy
Injection of the glenohumeral joint was successfully
performed in all 100 patients enrolled in this study
(Table 2). Overall access to the joint was gained on the
first attempt in 83 (83%) patients, on the second attempt in
14 (14%) patients and on the third attempt in 3 (3%)
patients. For fluoroscopic or US guidance the first attempt
scores were 72% and 94%, respectively. With fluoroscopy
a second and third attempt was needed in 22% and 6%,
respectively, whereas with US guidance a second attempt
in only 6%, and a third attempt was not needed in any of the
cases (Table 2).
The differences between the techniques in the frequency
of more than one attempt needed were statistically
significant (chi-square test df=3: p=0.026).
No complications of the vital structures, such as vessels,
nerves and tendons, were encountered clinically and with
MR imaging. Four (4%) patients had a vasovagal reaction,
two patients in the USp group and two patients in the FLa
group. No further complications were reported in any of the
groups as, for example, bleeding at the injection site,
swelling or compromise of movements.
Contrast material leakage
The various injection techniques were qualitatively
comparable with regard to extra-articular leakage of
contrast material. In 51% of all procedures minimal
(24%) and massive (27%) leakage occurred, which did
not hamper in any way the evaluation of the MR images.
Minimal leakage was most frequent in the FLa approach
(48%) and massive leakage in both posterior approaches
(FLp: 36% and USp: 32%) (Table 2).
Table 3 Required time (minutes) for US- and fluoroscopic-guided glenohumeral injection
TRoom
Min – max (mean/median)
FLa 07:00 – 33:00 (17:03/17:00)
FLp 12:00 – 29:00 (20:05/20:00)
USa 06:00 – 15:00 (09:54/10:00)
USp 05:00 – 16:00 (09:18/09:00)
FL(a + p) 07:00 – 33:00 (18:36/18:00)
US(a + p) 05:00 – 16:00 (09:36/09:00)
TUS:TFL 71%−48% (52%)
Kruskal-Wallis p<0.001
TRoom = time that the room is occupied by patient. TProcedure = time required for injection (skin to skin), TRadiologist = overall time radiologist
in the US or fluoroscopy room
USa: US-guided anterior injection, USp: US-guided posterior injection, FLa: fluoroscopic-guided anterior injection, FLp: fluoroscopic-
guided posterior injection. FL(a + p): fluoroscopic-guided anterior and posterior injection, US(a + p): US-guided anterior and posterior
injection, TUS:TFL: percentage of needed room, procedure and radiologist time with US guidance in relation to the time span for fluoroscopic
guidance
727
The differences in non-compromising leakage were
statistically significant (chi-square test, df=6: p=0.045).
Time assessment
Fluoroscopy and US room times, overall procedure times
and radiologist’s times are summarised in Table 3 as
minimum - maximum times (mean).
The mean room times for US guidance were signifi-
cantly shorter when compared to the time needed using
fluoroscopic guidance (Table 3). The shortest mean
procedure time required was noted for the USa approach
(1:34 min). The longest mean procedure time noted was
that using the FLp approach (9:48 min). Also noteworthy is
the difference in mean procedure time between the FLa
(4:09 min) and FLp approach (9:48 min). The minimum
procedure times were similar among all four approaches;
however, the maximum procedure times were significantly
shorter using US guidance (Table 3).
On average the procedure under US guidance was
shorter than under fluoroscopic guidance, using signifi-
cantly less (>50%) room time and radiologist time
(Table 3).
Discomfort
The VAS score obtained before and after shoulder injection
is summarised in Table 4. The VAS scores before the
procedure varied among the four different procedures, but
not significantly so (Kruskal-Wallis p=0.108). The varia-
tion in the VAS scores post-procedure was a little bit larger
and statistically significant (Kruskal-Wallis p=0.023). In
three of the four groups there was a general tendency for
TProcedure TRadiologist
Min – Max (mean/median) Min – max (mean/median)
00:30 – 20:00 (04:09/11:43) 03:00 – 27:00 (09:50/08:00)
00:45 – 23:00 (09:48/09:00) 10:00 – 27:00 (17:58/19:00)
00:30 – 06:00 (01:34/01:00) 04:00 – 13:15 (06:19/06:00)
00:30 – 07:30 (03:24/03:00) 01:56 – 12:00 (05:48/05:00)
00:30 – 23:00 (06:58/07:00) 03:00 – 27:00 (13:54/15:00)
00:30 – 07:30 (02:29/02:00) 01:56 – 13:15 (06:03/06:00)
100%−33% (36%) 64%−49% (44%)
p<0.001 p<0.001
728
Table 4 VAS pain score for US- and fluoroscopy-guided glenohumeral injections
Pre-procedure Post-procedure VAS difference
Min–max (mean) Min–max (mean) Mean
FLa 0 – 90 (30) 0 – 100 (39) +9
FLp 3 – 100 (42) 0 – 100 (28) −14
USa 0 – 75 (27) 0 – 70 (16) −11
USp 0 – 80 (38) 0 – 80 (27) −11
USa: US-guided anterior injection, USp: US-guided posterior injection, FLa: fluoroscopic-guided anterior injection, FLp: fluoroscopic-
guided posterior injection, VAS-difference: VAS score post-procedure - VAS score pre-procedure
patients to indicate that the procedure was less painful than
they had expected. In 44 patients the VAS score decreased
following injection, whereas in 28 patients it increased, and
in 28 patients the VAS score measured pre- and post-
procedure remained equal. The mean VAS score of the
FLp, USa and USp injections decreased 14, 11 and 11
points following injection, respectively, while it increased
with 9 points in the FLa group (Kruskal-Wallis p=0.001).
In fact, the post-procedure VAS score of the FLa procedure
increased in 60% of the patients. There was a higher
average pain score after FLa injection as compared to FLp.
Patients who underwent US-guided procedures reported
less pain than those who underwent the fluoroscopic-
guided procedures. The USa approach was rated with the
lowest pre- and post-injection VAS scores.
Discussion
The main advantage of image-guided glenohumeral joint
injection over blind injection is that the needle position can
be confirmed and injection of contrast medium can be
controlled. This is especially advantageous in teaching
hospitals (when training residents) and when the number of
MR arthrographies are limited.
The current study describes four different image-guided
approaches. Intra-articular deposition of contrast material
was successful in all patients, which is comparable with
reported results in the literature [2, 3, 10, 13]. The success
rate of the first attempt with US guidance (97%) was
significantly better compared to fluoroscopic guidance
(72%).
In the literature the accuracy of “blind” glenohumeral
injections varies from 26-100% [15–19]. Catalano et al.
[19]] showed that with a palpation-directed posterior
approach, the glenohumeral joint could be entered
successfully on respectively the first, second and third
attempt in 85%, 13% and 2% of the cases [19].
In this study the US procedure was less time consuming
than the fluoroscopic-guided procedure (2.30 min versus
7 min, i.e., only 36% of the time needed with fluoroscopic
guidance). This may be due to the received pre-procedural
Decrease Increase Equal
No. of patients No. of patients No. of patients
3 (12%) 15 (60%) 7 (28%)
15 (60%) 4 (16%) 6 (24%)
13 (52%) 4 (16%) 8 (32%)
13 (52%) 5 (20%) 7 (28%)
local anaesthetics and the injection with iodinated contrast
to confirm the intra-articular position. The reported time of
blind injection by Catalano was 3 min [19]. The occupancy
of the US room is only 52% of the fluoroscopy room
(Table 3).
The figures of leakages are summarised in Table 2. The
number is high compared to those reported by Catalano et
al. [19]. This may be due to strict criteria. Every small
amount of contrast material along the needle tract was graded
minimal leakage. The frequent leakage did not cause
interpretative difficulties. All patients were clinically sus-
pected of having anterior labral problems, and therefore
posterior leakage did not hamper interpretation. Contrast
material anteriorly did not compromise diagnostic quality,
because the contrast medium was usually depicted in close
relationship to the needle tract. In six cases massive leakage
was obviously due to capsular disruption (n=3), pathology of
the labrum (n=2) and a full-thickness rotator cuff tear (n=1).
Patients who undergo arthrography in general experi-
ence less pain than expected [23]. In our study 44% of the
patients considered discomfort less than expected and 28%
more than expected. However, in the subgroup of patients
who underwent the FLa approach (Table 4), 60%
experienced more discomfort than expected. This can be
explained by the fact that no local anaesthetics and a
thicker needle (20 gauge) were used and the fact that
manipulation of the stylet and syringe causes unintended
movements of the needle.
In this study four minor complications, e.g., vasovagal
reactions, were reported, which resolved without medical
intervention: two in the USp group and two in the FLa
group. Other minor complications included pain, urticaria
and headaches [25]. All four procedures were difficult due
to adipositas (n=3) and postoperative status (n=1). Hugo
[25] showed in a multi-institutional survey a total compli-
cation rate of 3.6%. Serious complications account for
0.02% and consist mainly of infections and rarely of
anaphylaxis and vascular complications [25].
In our study there were no advantages comparing the
anterior approach with the posterior approach. Some
authors [2, 9, 10, 14, 19] advocate the posterior approach,
because most pathologies of the stabilising structures of the
 729

glenohumeral joint are encountered on the anterior aspect
of the joint. Chung [9] shows that if a standard anterior
fluoroscopic approach is used, the needle may traverse the
primary stabilisers. To overcome this drawback a modified
anterior approach through the rotator interval can be
performed [13]. This is comparable with the US-guided
anterior approach. With this approach the needle entry site
is at the level between the coracoid process and the superior
medial quadrant of the humeral head, which is cranial to the
stabilising structures of the shoulder. This limits the risk of
compromising diagnostic quality because of leakage of
contrast material.
This study was not a strict comparative study between US
and fluoroscopic techniques because all radiologists kept
their own routine, introducing variables like needle size and
the use of local anaesthetics. Also the differences in injection
skills may play a role. Nevertheless, an important observa-
tion of this study is the wide variation in delivered patient
care. Although this study is too small to analyse the
contribution of different factors to this variation, it is
important for physicians to be aware of these phenomena.
The results suggest that US-guided glenohumeral joint
injection is preferable to fluoroscopic-guided glenohumeral
joint injection. To confirm the findings a prospective study
without variables such as needle size and local anaesthetics
is needed. Furthermore, the number of operators should be
extended to minimise the effect of differences in operator
skills.
Conclusion
The four image-guided injection techniques are successful
in injection of contrast material into the glenohumeral joint.
Although the effect of other variables, such as size of the
injection needle and the use of local anaesthetics, needs to
be investigated, we encourage US-guided injections and
especially the anterior approach, because in this study it
was significantly less time consuming, more successful on
the first attempt, can be performed with less patient
discomfort and obviates the need for radiation and iodine
contrast.
Acknowledgment The authors gratefully thank Stephan Muurling
for his dedicated contribution in preparing the drawings in this
article.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which
permits any noncommercial use, distribution, and reproduction in
any medium, provided the original author(s) and source are credited.

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